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Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Main Outcomes and Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.

Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation.

Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states. (Author abstract)

Colorado is poised this year to consider passing a comprehensive paid family and medical leave measure. Despite several unsuccessful attempts in recent years, changes in the state legislature and in voter sentiment point to building momentum in support of the policy. Passing it would make Colorado the seventh state in the U.S., plus the District of Columbia, to pass a statewide initiative. Drawing from data about similar programs in other states, this report examines what a comprehensive paid family and medical leave initiative might look like in Colorado. Specifically, we estimate that approximately 5% of eligible workers per year are likely to access leave benefits under the new program, with an average weekly benefit of about $671. To fund the program, workers and private-sector employers will each need to contribute about .34% of wages each year. At this premium rate, the program will be able to fully fund a wage replacement scheme that matches or comes close to matching wages of the lowest earners, with a maximum weekly benefit cap of either $1000 or $1200/week. Overall, the...

Colorado is poised this year to consider passing a comprehensive paid family and medical leave measure. Despite several unsuccessful attempts in recent years, changes in the state legislature and in voter sentiment point to building momentum in support of the policy. Passing it would make Colorado the seventh state in the U.S., plus the District of Columbia, to pass a statewide initiative. Drawing from data about similar programs in other states, this report examines what a comprehensive paid family and medical leave initiative might look like in Colorado. Specifically, we estimate that approximately 5% of eligible workers per year are likely to access leave benefits under the new program, with an average weekly benefit of about $671. To fund the program, workers and private-sector employers will each need to contribute about .34% of wages each year. At this premium rate, the program will be able to fully fund a wage replacement scheme that matches or comes close to matching wages of the lowest earners, with a maximum weekly benefit cap of either $1000 or $1200/week. Overall, the program seems feasible and is likely to bring a number of important benefits to workers and employers across the state, in exchange for a modest investment in the form of premium contributions. (Author abstract)

White Americans are dying at higher rates from drugs, alcohol, and suicides. And the sharpest increases are happening in rural counties, often in regions with long-standing social and economic challenges. The reasons behind these increases are unclear and complex. The opioid epidemic plays a role but is just one part of a larger public health crisis. Life expectancy in the US as a whole has fallen for the second year in a row, and the nation’s health relative to other countries has been declining for decades. Some combination of factors in American life must explain why the rise in mortality is greatest among white, middle-aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, greater social isolation, economic hardship, and distress among white workers over losing the security their parents’ generation once enjoyed. Also, over the past 30 years, income inequality and other social divides have widened, middle-class incomes have stagnated, and poverty rates have exceeded those of most rich countries. ...

White Americans are dying at higher rates from drugs, alcohol, and suicides. And the sharpest increases are happening in rural counties, often in regions with long-standing social and economic challenges. The reasons behind these increases are unclear and complex. The opioid epidemic plays a role but is just one part of a larger public health crisis. Life expectancy in the US as a whole has fallen for the second year in a row, and the nation’s health relative to other countries has been declining for decades. Some combination of factors in American life must explain why the rise in mortality is greatest among white, middle-aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, greater social isolation, economic hardship, and distress among white workers over losing the security their parents’ generation once enjoyed. Also, over the past 30 years, income inequality and other social divides have widened, middle-class incomes have stagnated, and poverty rates have exceeded those of most rich countries. Recent legislation and regulations, however, may prolong or intensify the economic burden on the middle class and weaken access to health care and safety net programs. The consequences of these choices are dire—not only more deaths and illness, but also escalating health care costs, a sicker workforce, and a less competitive economy. (Author abstract)

The U.S. Department of Housing and Urban Development (HUD) and the National Center for Health Statistics agreed in 2011 to link administrative records for individuals receiving housing assistance from HUD with records from the National Health Interview Survey. This report uses the linked data for 2006 through 2012 to present nationally representative estimates of demographic characteristics, health diagnoses and conditions, and health care access and utilization for HUD-assisted children ages 0–17. To provide context, similar estimates are provided for two other relevant subgroups: children residing in unassisted renter households with incomes below the federal poverty line and all children in the U.S. population. The report presents raw prevalence estimates to reflect actual conditions for each subgroup, and does not make statistical adjustments for age or other factors to support cross-group comparison of health conditions for similar individuals. Results demonstrate that assisted children suffer disproportionately from serious health conditions. (Author abstract)

The U.S. Department of Housing and Urban Development (HUD) and the National Center for Health Statistics agreed in 2011 to link administrative records for individuals receiving housing assistance from HUD with records from the National Health Interview Survey. This report uses the linked data for 2006 through 2012 to present nationally representative estimates of demographic characteristics, health diagnoses and conditions, and health care access and utilization for HUD-assisted children ages 0–17. To provide context, similar estimates are provided for two other relevant subgroups: children residing in unassisted renter households with incomes below the federal poverty line and all children in the U.S. population. The report presents raw prevalence estimates to reflect actual conditions for each subgroup, and does not make statistical adjustments for age or other factors to support cross-group comparison of health conditions for similar individuals. Results demonstrate that assisted children suffer disproportionately from serious health conditions. (Author abstract)

The prevalence of depression among rural women is nearly twice the national average, yet limited mental health services and extensive social barriers restrict access to needed treatment. We conducted key informant interviews with community health workers (CHWs) and diverse health care professionals who provide care to Appalachian women with depression to better understand the potential roles that CHWs may play to improve women’s treatment engagement. In the gap created by service disparities and social barriers, CHWs can offer a substantial contribution through improving recognition of depression; deepening rural women’s engagement within existing services; and offering sustained, culturally appropriate support. (Author abstract)

The prevalence of depression among rural women is nearly twice the national average, yet limited mental health services and extensive social barriers restrict access to needed treatment. We conducted key informant interviews with community health workers (CHWs) and diverse health care professionals who provide care to Appalachian women with depression to better understand the potential roles that CHWs may play to improve women’s treatment engagement. In the gap created by service disparities and social barriers, CHWs can offer a substantial contribution through improving recognition of depression; deepening rural women’s engagement within existing services; and offering sustained, culturally appropriate support. (Author abstract)